- Techniques and Instrumentation
- Open Access
Laparoscopic ovarian reconstruction without suturing after cystectomy for endometrioma
© Springer-Verlag Berlin Heidelberg 2014
Received: 22 February 2014
Accepted: 4 June 2014
Published: 24 June 2014
The primary aim of this study is to evaluate the technique of ovarian reconstruction without suturing after laparoscopic cystectomy of endometrioma. The secondary aim is to find the pregnancy rate following this technique. The study is a prospective observational study (Canadian Task Force classification II-3). The interventions used in the study are laparoscopic ovarian cystectomy and reconstruction without suturing. Laparoscopic ovarian cystectomy was performed in 240 patients between May 2007 and April 2012 of which 182 consecutive patients who met the selection criteria were enrolled in the study. Intraoperatively, the cyst wall is completely enucleated. Ovarian tissue is kept apposed together with a bowel grasper for 5 min to reconstruct the ovary. No sutures are used for approximation of ovarian edges. The median (range) operating time for cystectomy and reconstruction was 22 min (15–75), and estimated blood loss was 50 ml (30–200). The ovarian reconstruction was good in 84.6 % of the cases, average in 10 % and poor in 5.4 % of the patients. Postoperative scan on day 1 showed pelvic collection (blood) in five cases (20–50 ml). 9.89 % had intraovarian haematoma of 2–3 cm which resolved spontaneously. All patients were followed at 1 month and pregnancy rate was calculated after a minimum follow up of 12 months. Pregnancy rate was 50.7 % (33 patients) in our study. Approximation of ovarian surface for ovarian reconstruction was associated with shorter operating times, good morphological ovarian reconstruction and comparable pregnancy outcome. This technique requires further well-designed randomized controlled trials.
Endometriotic cysts are among the most common ovarian cysts encountered during surgery . Endometriomas can cause pelvic pain, infertility and dyspareunia, and the most preferred treatment is surgical . Various laparoscopic techniques have been described for the treatment of ovarian endometriomas: cyst wall laser vaporization preceded or not by medical therapy, drainage and bipolar coagulation of the cyst wall and stripping of the cyst wall [3–5]. Laparoscopic stripping is the preferred and safer technique . After stripping of the cyst wall, bleeding from the ovarian wound is controlled by bipolar coagulation, suturing, or tissue sealants [7, 8]. Each of these is associated with its own advantages and disadvantages.
We believe that the ovaries should be reconstructed after cystectomy for better functional outcome and reduced postoperative adhesions. We have been reconstructing the ovaries by approximating the ovarian edges with a bowel grasper for few minutes. This technique used minimal diathermy and avoided suturing, thus achieving shorter operating times without requiring endosuturing expertise. Without washing of the residual blood, we keep the adjacent surface of the ovary approximated with pressure for a few minutes and this helps in the reconstruction. The primary aim of this study is to evaluate the technique for ovarian reconstruction after laparoscopic cystectomy of the endometrioma. The secondary aim is to find the pregnancy rate following this technique.
Materials and methods
This is a prospective observational study done at Paul’s Hospital. A total of 240 patients underwent laparoscopic cystectomy for endometriosis between May 2007 and April 2012 at Paul’s Hospital. Of these, 182 consecutive patients with endometriotic cyst >3 cm in size were included in the study.
Preoperative clinical diagnosis of non-endometriotic cyst
Severely distorted pelvic anatomy at surgery (i.e., large size uterine fibroids, severe adhesions, congenital abnormalities) which required additional surgical procedure with consequent increase of operating times and possible conversion to laparotomy
Previous surgery for endometriosis
Patients treated with gonadotropin-releasing hormone (GnRH) analogues in the past 6 months
The institutional ethical committee of Paul’s Hospital approved the data collection, aggregation, identification and analysis for this study. Informed consent is obtained from all patients. Data regarding patient characteristics like age, body mass index, parity, previous surgeries and intraoperative details like duration of surgery, complications, estimated blood loss, duration of hospital stay and postoperative events are evaluated. The outcome is evaluated as complete reconstruction, complications, symptomatic relief and pregnancy rate. Patients were excluded from data analysis if endometriosis was not confirmed at histopathology.
Patients are admitted to the hospital on the day of surgery and kept nil per orally for 6 h prior to surgery. Bowel preparation is performed using sodium phosphate solution enema. Antibiotic prophylaxis is given at the time of induction of anaesthesia. Procedures are performed under general anaesthesia. All surgical procedures are carried out by the first author.
The patients are discharged on postoperative day 1 of surgery, and ultrasound examination is done for any pelvic or intraovarian haematoma before discharge (Fig. 6). All patients are followed up at 1 and 12 months and evaluated for any symptoms, and pregnancy rate was calculated. Postal questionnaires are sent to all patients, and telephonic enquiries are made at the end of the study. Minimum follow-up period is 1 year.
Since 2 years, we have been using dilute vasopressin for generalized vasoconstriction in the pelvis which helps in achieving initial haemostatic dissection of the adnexa and rectosigmoid. Twenty units of vasopressin is diluted in 100 ml of normal saline, and 40 to 60 ml of this solution is injected into the myometrium till the uterus is blanched. After anteverting the uterus with a Spackman cannula, salpingo-ovariolysis is done with sharp dissection. All fleshy adhesions from the uterus and pouch of Douglas are excised. All superficial endometriosis implants are coagulated, and deep ones are excised.
Demographic characteristics/patient details
No. of cases
30.37 ± 5.7
23.8 ± 4.2
Primary in fertility
Preoperative ultrasound findings
rAFS score median ( range) 24 (16–94)
No. of cases
Type of surgery
Cystectomy with unilateral adnexectomy
Unilateral cystectomy with myomectomy
Unilateral cystectomy with hysteroscopic polypectomy
Bilateral cystectomy with myomectomy
Bilateral cystectomy with hysteroscopic polypectomy
Bilateral cystectomy with hysteroscopic myomectomy
Duration of cystectomy and reconstruction
22 min (15–75)
50 ml (30–200)
Morphological appearance of reconstructed ovary
Good (>75 % reconstructed)
154 (84.6 %)
Average (50–75 %)
18 (10 %)
Poor (<50 %)
10 (5.4 %)
Suturing of the ovarian edges was required in two patients as the ovarian tissue had irregular edges, and reconstruction was not possible otherwise. None of the patients required conversion to laparotomy. No intraoperative or postoperative complication occurred. Length of postoperative stay was 1 day (1–4).
Postoperative ultrasound findings
Ultrasound—size of the ovary
No. of cases
160 (87.9 %)
> 6 cm
22 (12.1 %)
< 2 cm
164 (90.10 %)
18 (9.89 %)
< 20 ml
177 (97.25 %)
5 (2.75 %)
Of the 65 patients desiring fertility, 21 % of male partners had moderate oligoasthenozoospermia and 8 % had severe oligoasthenozoospermia. Thirty-three patients (50.7 %) conceived and 22 conceived spontaneously and 11 after assisted reproductive technology (ART).
In recent years, laparoscopy has become the gold standard for the treatment of ovarian endometriotic cysts [10, 11]. Laparoscopic stripping is the most preferred procedure . Good haemostasis is important after laparoscopic stripping of the cyst wall, and techniques like bipolar coagulation, sutures, fibrin sealants and direct pressure are used . Bipolar coagulation of the ovarian stroma is effective but damages the healthy ovarian tissue. When the ovarian capsule is left open after bipolar coagulation, it is associated with more adhesions as compared to the reconstruction of the ovary . In contrast, sutures are useful but also cause additional damage to the healthy tissue . Though suturing technique has been shown to cause less adhesions as compared to bipolar coagulation by various studies, sutures cause more postoperative adhesions as seen in the myomectomy studies and suturing is technically more demanding [7, 14]. Thus, avoiding suturing will be a simpler technique for the reconstruction. In this study, we used compression with bowel grasper for ovarian reconstruction after laparoscopic cystectomy of endometrioma.
Our technique of laparoscopic stripping is similar to other studies, except that vasopressin is injected on the uterus rather than on the endometrioma [6, 15]. On injecting vasopressin on the uterus, we get a generalized vasoconstriction of the pelvis which helps in maintaining a clear view without much bleeding during adhesiolysis.
In our study, the ovarian reconstruction was good in 84.6 %, average in 10 % and poor in 5.4 % of the patients. Suturing of the ovarian edges was required in two patients only. We could not find any study describing the morphological appearance of the ovary after laparoscopic cystectomy.
In our study, postoperative scan on day 1 showed pelvic fluid collection in five cases (20–50 ml). In 18 cases, haematoma in the ovary was greater than 2 cm (2–3 cm). Ninety percent of the patients had no intraovarian haematoma. None of these patients had evidence of infection and did not require any intervention. The pelvic collection and intraovarian haematoma resolved on serial ultrasound scans. In a case report by Ebert et al. using FloSeal for intraovarian haemostasis following cystectomy, day 2 ultrasound revealed a residuum of 10 mm within the ovary and residual fluid of less than 5 ml in cul-de-sac . Hence, the failure rate in our technique considering both morphological appearance (5.4 %) and postoperative ovarian haematoma >2 cm (10 %) was 15.4 %.
No. of cases
33 (50.7 %)
22 (66.6 %)
Assisted reproductive technology (ART)
11 (33.2 %)
28 (84.9 %)
The limitation of the present study is that it is an observational study, with no randomization, and we did not do a second look laparoscopy. Thus, further prospective randomized control trial studies are needed to validate our results.
Different techniques for haemostasis and ovarian reconstruction following cystectomy are use of bipolar coagulation, sutures, fibrin sealants and direct pressure. We reconstructed the ovaries by approximating the ovarian surface with a bowel grasper for few minutes, and it was associated with a successful outcome. Though this is a simpler technique, further well-designed randomized controlled trials are needed.
Conflict of interest
The authors, Dr. Paul P G, Dr. Harneeth Kaur, Dr. Dhivya Narasimhan, Dr. Gaurav Chopade and Dr. Dimple Kandhari declare that they have no conflict of interest. The authors alone are responsible for the content and writing of the paper.
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki declaration of 1975, as revised in 2000(5). Informed consent was obtained from all patients for being included in the study.
- Loh FH, Tan AT, Kumar J, Ng SC (1999) Ovarian response after laparoscopic ovarian cystectomy for endometriotic cysts in 132 monitored cycles. Fertil Steril 72:316–321PubMedView ArticleGoogle Scholar
- Valle RF, Sciarra JJ (2003) Endometriosis: treatment strategies. Ann N Y Acad Sci 997:229–239. doi:10.1196/annals.1290.026 PubMedView ArticleGoogle Scholar
- Brosens IA, Van Ballaer P, Puttemans P, Deprest J (1996) Reconstruction of the ovary containing large endometriomas by an extraovarian endosurgical technique. Fertil Steril 66(4):517–521PubMedGoogle Scholar
- Beretta P, Franchi M, Ghezzi F, Busacca M, Zupi E, Bolis P (1998) Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation. Fertil Steril 70:1176–1180PubMedView ArticleGoogle Scholar
- Canis M, Mage G, Wattiez A, Chapron C, Pouly JL, Bassil S (1992) Second look laparoscopy after laparoscopic cystectomy of large ovarian endometriomas. Fertil Steril 58:611–619Google Scholar
- Muzii L, Bellati F, Palaia I, Plotti F, Manci N, Zullo MA et al (2005) Laparoscopic stripping of endometriomas: a randomized trial on different surgical techniques. Part I: clinical results. Hum Reprod 20:1981–1986PubMedView ArticleGoogle Scholar
- Pellicano M, Bramante S, Guida M, Bifulco G, Di Spiezio SA, Cirillo D, Nappi C (2008) Ovarian endometrioma: postoperative adhesions following bipolar coagulation and suture. Fertil Steril 89(4):796–799PubMedView ArticleGoogle Scholar
- Ebert AD, Hollauer A, Fuhr N, Langolf O, Papadopoulos T (2009) Laparoscopic ovarian cystectomy without bipolar coagulation or sutures using a gelantine-thrombin matrix sealant (FloSeal): first support of a promising technique. Arch Gynecol Obstet 280:161–165PubMedView ArticleGoogle Scholar
- (1997) American, Society for Reproductive Medicine Revised classification of endometriosis: 1996. Fertil Steril 67:817–21Google Scholar
- Vercellini P, Somigliana E, Viganò P, De Matteis S, Barbara G, Fedele L (2009) The effect of second-line surgery on reproductive performance of women with recurrent endometriosis: a systematic review. Acta Obstet Gynecol Scand 88(10):1074–1082PubMedView ArticleGoogle Scholar
- Yeung PP, Shwayder J, Pasic RP (2009) Laparoscopic management of endometriosis: comprehensive review of best evidence. J Minim Invasive Gynecol 16(3):269–281PubMedView ArticleGoogle Scholar
- Takeuchi H, Awaji M, Hashimoto M, Nakano Y, Mitsuhashi N, Kuwabara Y (1996) Reduction of adhesions with fibrin glue after laparoscopic excision of large ovarian endometriomas. J Am Assoc Gynecol Laparosc 3(4):575–579PubMedView ArticleGoogle Scholar
- Fedele L, Bianchi S, Zanconato G, Bergamini V, Berlanda N (2004) Bipolar electrocoagulation versus suture of solitary ovary after laparoscopic excision of ovarian endometriomas. J Am Assoc Gynecol Laparosc 11(3):344–347PubMedView ArticleGoogle Scholar
- Dubuisson JB, Fauconnier A, Chapron C, Kreiker G, Nörgaard C (1998) Second look after laparoscopic myomectomy. Hum Reprod 13(8):2102–2106PubMedView ArticleGoogle Scholar
- Saeki A, Matsumoto T, Ikuma K, Tanase Y, Inaba F, Oku H, Kuno A (2010) The vasopressin injection technique for laparoscopic excision of ovarian endometrioma: a technique to reduce the use of coagulation. J Minim Invasive Gynecol 17(2):176–179PubMedView ArticleGoogle Scholar
- Pursifull NF, Morey AF (2007) Tissue glues and nonsuturing techniques. Curr Opin Urol 17(6):396–401PubMedView ArticleGoogle Scholar